Nursing Elites

1. A nurse is developing a teaching plan for the client with viral hepatitis. The nurse plans to tell the client which of the following in the teaching session?

• A. Activity should be limited to prevent fatigue
• B. The diet should be low in calories
• C. Meals should be large to conserve energy
• D. Alcohol intake should be limited to 2 oz. per day.

Correct answer: A

Rationale: The client with viral hepatitis should limit activity to avoid fatigue during the recuperation period. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.

2. The client has had a new colostomy created 2 days earlier. The client is beginning to pass malodorous flatus from the stoma. The nurse interprets that

• A. This indicates inadequate preoperative bowel preparation.
• B. This is a normal, expected event.
• C. The client is experiencing early signs of ischemic bowel.
• D. The client should not have the nasogastric tube removed.

Correct answer: B

Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy.

3. Crohn’s disease can be described as a chronic relapsing disease. Which of the following areas in the GI system may be involved with this disease?

• A. The entire length of the large colon
• B. Only the sigmoid area
• C. The entire large colon through the layers of mucosa and submucosa
• D. The small intestine and colon; affecting the entire thickness of the bowel

Correct answer: D

Rationale: Crohn's disease can affect any part of the gastrointestinal tract from the mouth to the anus, but it commonly affects the small intestine and colon, involving the entire thickness of the bowel wall.

4. A client has been diagnosed with gastroesophageal reflux disease. The nurse interprets that the client has dysfunction of which of the following parts of the digestive system?

• A. Chief cells of the stomach
• B. Parietal cells of the stomach
• C. Lower esophageal sphincter
• D. Upper esophageal sphincter

Correct answer: C

Rationale: The lower esophageal sphincter is a functional sphincter that normally remains closed except when food or fluids are swallowed. If relaxation of this sphincter occurs, the client could experience symptoms of gastroesophageal reflux disease.

5. The nurse aspirates 40 mL of undigested formula from the client’s nasogastric tube. Before administering an intermittent tube feeding, the nurse understands that the 40 mL of gastric aspirate should be

• A. Discarded properly and recorded as output on the client’s intake and output record.
• B. Poured into the nasogastric tube through a syringe with the plunger removed.
• C. Mixed with the formula and poured into the nasogastric tube through a syringe with the plunger removed.
• D. Diluted with water and injected into the nasogastric tube by putting pressure on the plunger.

Correct answer: B

Rationale: After checking the residual feeding contents, the gastric contents are reinstalled into the stomach by removing the syringe bulb or plunger and pouring the gastric contents into the syringe and through the nasogastric tube. Gastric contents should be reinstalled to maintain the client’s electrolyte balance. The gastric contents should be poured into the nasogastric tube through a syringe without a plunger and not injected by putting pressure on the plunger. Gastric contents do not need to be mixed with water or should the contents be discarded.

Similar Questions